Strokes in Patients With Injection Drug Use and Tricuspid Valve Endocarditis - A Case Series.

Research Design: In this study, we describe patients from a tertiary care safety-net hospital endocarditis registry with tricuspid valve infective endocarditis (TVIE), and concomitant acute or subacute ischemic stroke predominantly associated with injection drug use (IDU). We retrospectively obtained data pertinent to neurologic examinations, history of injection drug use (IDU), blood cultures, transthoracic/transesophageal echocardiography (TTE/TEE), neuroimaging, and Modified Rankin Scale (mRS) scores at discharge. Only those patients with bacteremia, tricuspid valve vegetations, and neuroimaging consistent with acute to subacute ischemic infarction and microhemorrhages in two cases were included in this series. Results: Of 188 patients in the registry, 66 patients had TVIE and 10 of these were complicated by ischemic stroke. Neurologic symptoms were largely non-specific, eight patients had altered mental status and only 3 had focal deficits. Nine cases were associated with IDU. Two patients had evidence of a patent foramen ovale on echocardiography. Blood cultures grew S. aureus species in 9 of the patients, all associated with IDU. Three patients died during hospitalization. The mRS score at discharge for survivors ranged 0-4. Conclusions: Patients with strokes from TVIE had heterogeneous presentations and putative mechanisms. We noted that robust neuroimaging is lacking for patients with TVIE from IDU and that such patients may benefit from neuroimaging as a screen for strokes to assist peri-operative management. Further inquiry is needed to elucidate stroke mechanisms in these patients.

Grayken lessons: the role of an interdisciplinary endocarditis working group in evaluating and optimizing care for a woman with opioid use disorder requiring a second tricuspid valve replacement.

BACKGROUND: Injection drug use-related endocarditis is increasingly common among hospitalized patients in the United States, and associated morbidity and mortality are rising. CASE PRESENTATION: Here we present the case of a 34-year-old woman with severe opioid use disorder and multiple episodes of infective endocarditis requiring prosthetic tricuspid valve replacement, who developed worsening dyspnea on exertion. Her echocardiogram demonstrated severe tricuspid regurgitation with a flail prosthetic valve leaflet, without concurrent endocarditis, necessitating a repeat valve replacement. Her care was overseen by our institution's Endocarditis Working Group, a multidisciplinary team that includes providers from addiction medicine, cardiology, infectious disease, cardiothoracic surgery, and neurocritical care. The team worked together to evaluate her, develop a treatment plan for her substance use disorder in tandem with her other medical conditions, and advocate for her candidacy for valve replacement. CONCLUSIONS: Multidisciplinary endocarditis teams such as these are important emerging innovations, which have demonstrated improvements in outcomes for patients with infective endocarditis and substance use disorders, and have the potential to reduce bias by promoting standard-of-care treatment.

Surgical outcomes of pulmonary valve infective endocarditis: A US population-based analysis.

BACKGROUND: Pulmonary valve infective endocarditis (PVIE) represents a rare subset of right-sided IE. This study aimed to evaluate the population-level surgical outcomes of PVIE in the United States. METHODS: We performed a retrospective observational study using the 2002-2017 National Inpatient Sample database. We included hospitalizations with both IE and PV interventions. We excluded Tetralogy of Fallot, congenital PV malformation, and those who underwent the Ross procedure. The primary outcome was in-hospital mortality. The secondary outcomes included major complications and length of hospital stay. RESULTS: We identified 677 PVIE hospitalizations that underwent surgical treatment, accounting for 0.06% of all IE hospitalizations. The mean age was 35.2 ± 1.7 years; 60.0% were White, 30.3% were women, and 11.4% were intravenous drug users. Most were treated in large-sized (70.1%) urban teaching (88.8%) hospitals. Close to 30% of patients received at least one concomitant valve procedure. The in-hospital mortality was 5.5% for the entire cohort, and the median length of stay was 16 days. Major complications included complete heart block (8.7%), acute kidney injury (8.1%), and stroke (1.3%). The differences in mortality and complications rate comparing PV repair and replacement were not statistically significant. PV repair was associated with a longer length of hospital stay compared to PV replacement (median: 25 vs. 16 days, p = 0.03). CONCLUSIONS: This study defines the population-level in-hospital outcomes after surgical intervention of PVIE. Surgically treated PVIE patients are associated with relatively low mortality and morbidities. The outcomes between PV replacement and repair are similar.

Validation of a Crisis Standards of Care Model for Prioritization of Limited Resources During the Coronavirus Disease 2019 Crisis in an Urban, Safety-Net, Academic Medical Center.

OBJECTIVES: The coronavirus disease 2019 pandemic has overwhelmed healthcare resources even in wealthy nations, necessitating rationing of limited resources without previously established crisis standards of care protocols. In Massachusetts, triage guidelines were designed based on acute illness and chronic life-limiting conditions. In this study, we sought to retrospectively validate this protocol to cohorts of critically ill patients from our hospital. DESIGN: We applied our hospital-adopted guidelines, which defined severe and major chronic conditions as those associated with a greater than 50% likelihood of 1- and 5-year mortality, respectively, to a critically ill patient population. We investigated mortality for the same intervals. SETTING: An urban safety-net hospital ICU. PATIENTS: All adults hospitalized during April of 2015 and April 2019 identified through a clinical database search. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 365 admitted patients, 15.89% had one or more defined chronic life-limiting conditions. These patients had higher 1-year (46.55% vs 13.68%; p < 0.01) and 5-year (50.00% vs 17.22%; p < 0.01) mortality rates than those without underlying conditions. Irrespective of classification of disease severity, patients with metastatic cancer, congestive heart failure, end-stage renal disease, and neurodegenerative disease had greater than 50% 1-year mortality, whereas patients with chronic lung disease and cirrhosis had less than 50% 1-year mortality. Observed 1- and 5-year mortality for cirrhosis, heart failure, and metastatic cancer were more variable when subdivided into severe and major categories. CONCLUSIONS: Patients with major and severe chronic medical conditions overall had 46.55% and 50.00% mortality at 1 and 5 years, respectively. However, mortality varied between conditions. Our findings appear to support a crisis standards protocol which focuses on acute illness severity and only considers underlying conditions carrying a greater than 50% predicted likelihood of 1-year mortality. Modifications to the chronic lung disease, congestive heart failure, and cirrhosis criteria should be refined if they are to be included in future models.

Effect of Publicly Reported Aortic Valve Surgery Outcomes on Valve Surgery in Injection Drug- and Non-Injection Drug-Associated Endocarditis.

BACKGROUND: Injection drug use-associated infective endocarditis (IDU-IE) is rising and valve surgery is frequently indicated. The effect of initiating public outcomes reporting for aortic valve surgery on rates of valve surgery and in-hospital mortality for endocarditis is not known. METHODS: For an interrupted time series analysis, we used data from the National Inpatient Sample, a representative sample of United States inpatient hospitalizations, from January 2010 to September 2015. We included individuals aged 18-65 with an International Classification of Diseases, Ninth Revision (ICD-9) diagnosis of endocarditis. We defined IDU-IE using a validated combination of ICD-9 codes. We used segmented logistic regression to assess for changes in valve replacement and in-hospital mortality rates after the public reporting initiation in January 2013. RESULTS: We identified 7322 hospitalizations for IDU-IE and 23 997 for non-IDU-IE in the sample, representing 36 452 national IDU-IE admissions and 119 316 non-IDU admissions, respectively. Following the implementation of public reporting in 2013, relative to baseline trends, the odds of valve replacement decreased by 4.0% per quarter (odds ratio [OR] 0.96, 95% confidence interval [CI] 0.93-0.99), with no difference by IDU status. The odds of an in-patient death decreased by 2.0% per quarter for both IDU-IE and non-IDU-IE cases following reporting (OR 0.98, 95% CI 0.97-0.99). CONCLUSIONS: Initiating public reporting was associated with a significant decrease in valve surgery for all IE cases, regardless of IDU status, and a reduction in-hospital mortality for patients with IE. Patients with IE may have less access to surgery as a consequence of public reporting. To understand how reduced valve surgery impacts overall mortality, future studies should examine the postdischarge mortality rate.

Neurological Complications of Endocarditis: A Multidisciplinary Review with Focus on Surgical Decision Making.

Infective endocarditis (IE) is a systemic disease with many potential neurologic manifestations including ischemic and hemorrhagic strokes, cerebral microbleeding, infectious intracranial aneurysms, meningitis, brain abscesses, and encephalopathy. The majority of left-sided (heart) IE patients have brain lesions that may alter management decisions, warranting the systematic use of magnetic resonance imaging. Many patients require surgical treatment of valvular disease, and central nervous system lesions weigh into decision making. Data regarding the timing of surgery are conflicting, but earlier surgery appears to be safe in most ischemic strokes, while ideally surgery should be delayed for 3 to 4 weeks in patients with hemorrhagic strokes. IE requires a multidisciplinary team to collaboratively care for the patient. In this article, we review the current understanding and management of the neurological complications of IE and their impact on the performance and timing of cardiac surgery.

Management of Inflammatory Cardiac Masses.

Systemic rheumatologic and inflammatory disorders can affect almost any organ system, including the heart. The cardiac valves, conduction system, myocardium, endocardium, pericardium, and coronary arteries may be affected. Intracardiac masses may develop as part of the disease process or a consequence of their therapy, such as methotrexate-associated nodulosis. Optimal therapy in these cases is not known, since many patients are asymptomatic and the potential benefit of surgical excision must be weighed against its associated morbidity and mortality. Importantly, these inflammatory masses must be differentiated from thrombus, infection, and primary and metastatic tumors. We present three cases of inflammatory cardiac masses associated with rheumatoid arthritis and Wegener's granulomatosis, which were successfully treated conservatively, and propose a management algorithm. The benefits of such an approach must be individualized and weighed against the risks of systemic embolization, stroke and obstruction.

Novel approach to cardiac alarm management on telemetry units.

BACKGROUND: General medical-surgical units struggle with how best to use cardiac monitor alarms to alert nursing staff to important abnormal heart rates (HRs) and rhythms while limiting inappropriate and unnecessary alarms that may undermine both patient safety and quality of care. When alarms are more often false than true, the nursing staff's sense of urgency in responding to alarms is diminished. In this syndrome of "clinical alarm fatigue," the simple burden of alarms desensitizes caregivers to alarms. Noise levels associated with frequent alarms may also heighten patient anxiety and disrupt their perception of a healing environment. Alarm fatigue experienced by nurses and patients is a significant problem and innovative solutions are needed. OBJECTIVE: The purpose of this quality improvement study was to determine variables that would safely reduce noncritical telemetry and monitor alarms on a general medical-surgical unit where standard manufacturer defaults contributed to excessive audible alarms. METHODS: Mining of alarm data and direct observations of staff's response to alarms were used to identify the self-reset warning alarms for bradycardia, tachycardia, and HR limits as the largest contributors of audible alarms. In this quality improvement study, the alarms for bradycardia, tachycardia, and HR limits were changed to "crisis," requiring nursing staff to view and act on the alarm each time it sounded. The limits for HR were HR low 45 bpm and HR high 130 bpm. RESULTS: An overall 89% reduction in total mean weekly audible alarms was achieved on the pilot unit (t = 8.84; P < .0001) without requirement for additional resources or technology. Staff and patient satisfaction also improved. There were no adverse events related to missed cardiac monitoring events, and the incidence of code blues decreased by 50%. CONCLUSIONS: Alarms with self-reset capabilities may result in an excess number of audible alarms and clinical alarm fatigue. By eliminating self-resetting alarms, the volume of audible alarms and associated clinical alarm fatigue can be significantly reduced without requiring additional resources or technology or compromising patient safety and lead to improvement in both staff and patient satisfaction.

Alcoholic and cocaine-associated cardiomyopathies.

Alcohol and cocaine use are associated with significant cardiovascular complications, including cardiomyopathy. The pathophysiologic mechanisms underlying the development of these toxic cardiomyopathies vary depending on the inciting agent but include direct toxic effects, neurohormonal activation, altered calcium homeostasis, and oxidative stress. The typical patient with alcoholic cardiomyopathy is a long-term excessive alcohol consumer who is otherwise indistinguishable from other patients with nonischemic cardiomyopathy. The typical patient with cocaine cardiomyopathy is a young male smoker who presents with signs of adrenergic excess. Management of these patients is similar to that of patients with other forms of dilated cardiomyopathy, although beta-blockers should be avoided in patients with cocaine-associated heart failure and benzodiazepines should be given in this setting to blunt adrenergic excess. Left ventricular function may improve dramatically with abstinence from alcohol or cocaine. Unfortunately, the rate of recidivism is high and left ventricular dysfunction and symptomatic heart failure often recurs.

The relationship between aldosterone, oxidative stress, and inflammation in chronic, stable human heart failure.

BACKGROUND: Aldosterone antagonists reduce morbidity and mortality in patients with severe heart failure, but the mechanisms responsible are not fully understood. Observations in animal models suggest that elevated levels of aldosterone promote oxidative stress and inflammation in the myocardium. It is unknown if these findings are relevant to heart failure patients who may have much lower aldosterone levels. METHODS AND RESULTS: We therefore examined the relationship of plasma aldosterone levels to markers of oxidative stress, inflammation and matrix turnover in 58 patients with chronic, stable heart failure from systolic dysfunction (LV ejection fraction <0.40) who were not receiving aldosterone antagonists. Chronic, stable heart failure patients had modestly elevated levels of aldosterone. Additionally, these patients had elevated levels of 8-isoprostaglandin F(2alpha), C-reactive protein, soluble intercellular adhesion molecule-1, osteopontin, brain natriuretic peptide, procollagen type III aminoterminal peptide, and tissue inhibitor of metalloproteinase-1. Among these patients with heart failure, aldosterone levels correlated with 8-iso-PGF(2alpha) (P = .003), ICAM-1 (P = .008), and TIMP-1 (P = .006) after adjustment for age, gender, race, diabetes, smoking, heart rate, left ventricular mass, and body mass index. CONCLUSION: In chronic, stable heart failure patients on standard therapy, higher aldosterone levels are associated with systemic evidence of oxidative stress, inflammation, and matrix turnover.